Standard Insurance Company
Enrollment and Change
To Be Completed By Human Resources Maintain completed form for your records.
Group Number
Division
Billing Category
Date of Employment
643908
To Be Completed By Applicant Check all boxes and complete all sections that apply. Return completed form to your Human
Resources Department.
Your Name (Last, First, Middle)
Your Social Security Number
Birth Date
Your Address
City
State
Employer Name
Job Title/Occupation
Male
ZIP
Female
Phone Number
Gallaudet University
Hours Worked Per Week
Earnings $________________ Per:
Hour
Week
Month
Year
Change Use this section only when you wish to make a change after insurance becomes effective. Complete all boxes and sections that
apply.
Beneficiary Change Fill out the Beneficiary Section below.
Name Change
Add or
Former name _______________________________________________________________________________
Delete Dependent
Date of add/delete ___________________
Reason _________________________________
Other _________________________________________________________________________________________________________
Coverage Check with your Human Resources Department about coverage options available to you and Evidence Of Insurability requirements.
Life Insurance
Life with AD&D (Employer Paid)
Additional/Optional Life
Your requested amount $_______________
Dependents Life Insurance
Spouse Life Requested amount $_______________
Spouse Name______________________________________________________ Date of Birth_______________________
Child(ren) Life Requested amount $_______________
Long Term Disability
Employer Paid LTD
Beneficiary This designation applies to Life/Life with AD&D Insurance available through your Employer, if any. Designations are not
valid unless signed, dated, and delivered to the Employer during your lifetime. See page 2 for further information.
Primary - Full Name
Address
Soc. Sec. No.
Relationship
% of Benefit
Contingent - Full Name
Address
Soc. Sec. No.
Relationship
% of Benefit
Signature I wish to make the choices indicated on this form. If electing coverage, I authorize deductions from my wages to cover my
contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change.
Member/Employee Signature Required __________________________________________ Date (Mo/Day/Yr) _________________
SI 7533D-643908 (3/16)
1 of 2
(10/09)
Beneficiary Information

Your designation revokes all prior designations.

Benefits are only payable to a contingent Beneficiary if you are not survived by one or more primary
Beneficiary(ies).

If you name two or more Beneficiaries in a class:
1.
Two or more surviving Beneficiaries will share equally, unless you provide for unequal shares.
2.
If you provide for unequal shares in a class, and two or more Beneficiaries in that class survive, we will pay
each surviving Beneficiary his or her designated share. Unless you provide otherwise, we will then pay the
share(s) otherwise due to any deceased Beneficiary(ies) to the surviving Beneficiaries pro rata based on the
relationship that the designated percentage or fractional share of each surviving Beneficiary bears to the
total shares of all surviving Beneficiaries.
3.
If only one Beneficiary in a class survives, we will pay the total death benefits to that Beneficiary.

If a minor (a person not of legal age), or your estate, is the Beneficiary, it may be necessary to have a guardian
or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust
or trustee, the written trust must be identified in the Beneficiary designation. For example, “Dorothy Q. Smith,
Trustee under the trust agreement dated
.”

A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or
change a Beneficiary designation. If you have any questions, consult your legal advisor.

Dependents Insurance, if any, is payable to you, if living, or as provided under your Employer’s coverage under
the Group Policy.
SI 7533D
2 of 2
(5/09)